Obsessive compulsive

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1 CHAPTER 1 INTRODUCTION 1.1. Background Obsessive-compulsive disorder (OCD) is a relatively common, if not always recognized, disorder that is often associated with significant distress and impairment in functioning. Due to stigma and lack of recognition, individuals with OCD often must wait many years before they receive a correct diagnosis and indicated treatment. In severe presentations, this disorder is quite disabling and is appropriately characterized as an example of severe and persistent mental illness. The obsessions are usually related to a sense of harm, risk, or danger. Common obsessions include concerns about contamination, doubts, fear of loss or letting go, and fear of physically injuring someone. More than 95% of people with OCD feel compelled to performed rituals which is repetitive, purposeful intentional acts. This rituals define what we called a compulsion is. Rituals used to control an obsession or neutralize it for example people who afraid of contamination will wash his hand repeatedly until he is satisfy with it no matter how many times he might wash his hand.

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1.1. Background

Obsessive-compulsive disorder (OCD) is a relatively common, if not always recognized,

disorder that is often associated with significant distress and impairment in functioning. Due to

stigma and lack of recognition, individuals with OCD often must wait many years before they

receive a correct diagnosis and indicated treatment. In severe presentations, this disorder is quite

disabling and is appropriately characterized as an example of severe and persistent mental


The obsessions are usually related to a sense of harm, risk, or danger. Common

obsessions include concerns about contamination, doubts, fear of loss or letting go, and fear of

physically injuring someone.

More than 95% of people with OCD feel compelled to performed rituals which is

repetitive, purposeful intentional acts. This rituals define what we called a compulsion is. Rituals

used to control an obsession or neutralize it for example people who afraid of contamination will

wash his hand repeatedly until he is satisfy with it no matter how many times he might wash his

hand. These people are also known as washers, there are also other types for example checkers

and hoarders. Most rituals can be observed while others might need a detail history taking and

observation. Obsessions are not always accompanied by compulsion.

Most people with OCD are aware that their obsessive thoughts do not reflect actual risk

and that their compulsive behaviors are ineffective. OCD, therefore, differs from psychotic

disorders, in which one’s lose contact with reality. OCD also differs from obsessive-compulsive

personality disorder, in which specific personal traits are defined.

It is often helpful to individuals suffering from OCD to point out that anxiety comes first,

before the obsession or compulsion which are seen as defense against anxiety. The patient may

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otherwise regard them as evidence of madness. It should also be noted that depression and

anxiety are common in OCD.

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2.1. Definition

An obsession is defined as an idea, impulse, or images which intrude into the conscious

awareness repeatedly. It is recognized as one’s own idea, impulse or image but perceived as

absurd or alien and irrational to one’s personality. The patient tries to resist against it but unable

to do s. Thus failure to resist will lead to marked distress to the patient.

A compulsion is define as a form of behavior which usually follows or associated with

obsession. It is aimed to either preventing or neutralizing the distress or fear arising out of

obsession. The behavior or rituals usually is not realistic and is either irrational or excessive.

Insight of the patient is present and so the patient realizes the irrationality of compulsion. The

behavior is performed with a sense of subjective compulsion which is urge or impulse to act on


2.2. Epidemiology

The prevalence of OCD estimated in the general population are between 0.5 to 1 percent.

About 10 percent of patient with neurotic disorder suffer from OCD and 1 percent are among the

psychiatric outpatient population. Minor obsessive compulsive symptoms may be present in up

to 17 percent of the population. Studies from United States of America (USA) suggest that 2 to 3

percent of the population may suffer from it at sometime at their lives.

The overall prevalence of OCD is equal in males and females, although the disorder more

commonly presents in males in childhood or adolescence and in females in their twenties.

Childhood-onset OCD is more common in males and more likely to be comorbid with attention

deficit hyperactivity disorder (ADHD) and Tourette disorder.

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Two thirds of individuals have an age of onset in the early 20s, before 25s years, with the

mean age of about 22 years. It can even begin in childhood with peak age of onset of 10 to 14

years old. Those with checking rituals have earlier mean age of onset of 18 years, compared to

other groups with mean age of 27 years. The course tends to be chronic with exacerbation.

OCD appears to have a similar prevalence in different races and ethnicities, although

specific pathological preoccupations may vary with culture and religion.

2.3. Etiology

Several causative factors have been explored in the past but no clear etiology of obsessive

compulsive disorder is known yet. Some of the important theories have been proposed and these

theories include:

2.3.1. Biological Theories

There is an increased genetic predisposition in first degree relatives (5-7%) and greater

concordance between monozygotic as compared to dizygotic twins. However the types of

obsessive and compulsive are not always the same in different affected family members. There is

also genetic association between Tourette’s syndrome, chronic motor tic disorder and OCD.

Indeed, up to 20 percent of individuals with OCD may have tics, which in turn are suggestive of

basal ganglia disorder.

There is also an increased incidence of OCD in those who have suffered brain injury, for

example due to head injuries, encephalitis or syphilis. Evidence for a neurobiological basis has

been accrued from positron emission tomography (PET) and magnetic resonance imaging (MRI)

techniques, in which orbitofrontal and cingulated cortices and basal ganglia abnormalities have

been found, as have reductions bilaterally in the size of the caudate nuclei and retrocallosal white

matter. These findings all suggest structural abnormalities in the brain in at least some cases of


There is also evidence for abnormalities in serotonin (5-HT) transmission in the central

nervous system. Some children and adolescents develop OCD after β-haemolytic streptococcal

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infections, suggesting an autoimmune etiology. However, at present moment, there is no

conclusive evidence for OCD having clearly proven organic etiology.

2.3.2. Psychodynamic Theory

In Freudian psychoanalytic theory OCD originates at the anal training stage development.

When in early childhood, the anal sadistic phase was disturbed while this is the stage when the

child began to understand self autonomy. Due to harsh toilet training this child began to confuse

his own autonomy and others. The anal sadistic phase will regress together with the anxiety

related to oedipal conflicts at present thus then began to build reinforcement of anal or

aggressive impulses.

The anankastic personality trait will be disguised by the reaction formation and when this

is not enough the new defenses mechanism is created. The defenses mechanism are isolation of

affect that contributed for the obsessive thought, undoing which then contributed for the

compulsion, and displacement that acted out as phobias.

In the isolation of affect, the ego removes the affect from the anxiety-causing idea. The

idea is thus weakened, but remains still in the consciousness. The affect however becomes free

and attached itself to other neutral ideas by symbolic associations. Thus these neutral ideas

become anxiety-provoking and turn into obsession. This happens only when isolation of affect is

not fully successful. When both the idea and affect are repressed and there is no obsession. The

undoing will leads to compulsion which prevents or undoes the fear consequences of obsession.

This mechanism has been explained in slight detail as this theory attempts to describe the

probable causation of OCD in remarkably systematic manner. However, it must be remembered

that this is only a theory and whether it is true or not, is a matter of conjecture.

Thus, the psychodynamic theory explains OCD by defensive regression to anal-sadistic

phase of development with the use of isolation, undoing, and displacement to produce obsessive

compulsive symptoms.

2.3.3. Behavioral Theory

The behavioral theory explains obsession as condition stimuli to anxiety that is similar to

phobias. While compulsions have been described as learned behavior which decrease the anxiety

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associated with obsessions. This decrease in anxiety positively reinforces the compulsive acts

and they become ‘stable’ learned behaviors.

Behavioral or learning theory is not able to explain the causation of OCD adequately but

is very useful in its treatment.

2.4. Diagnosis

OCD is classified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth

Edition, Text Revision (DSM-IV-TR) as an anxiety disorder.[1 ]It is characterized by distressing

intrusive obsessive thoughts and/or repetitive compulsive actions (which may be physical or

mental acts) that are clinically significant. The specific DSM-IV-TR criteria for OCD are as


A. The individual expresses either obsessions or compulsions.

1. Obsessions as define by (1), (2), (3) and (4):

1. Recurrent and persistent thoughts, impulses, or images are experienced at some

time during the disturbance as intrusive and inappropriate and cause marked

anxiety and distress. Those with this disorder recognize the craziness of these

unwanted thoughts (such as fears of hurting their children) and would not act on

them, but the thoughts are very disturbing and difficult to tell others about.

2. The thoughts, impulses, or images are not simply excessive worries about real-life


3. The person attempts to suppress or ignore such thoughts, impulses, or images or

to neutralize them with some other thought or action.

4. The person recognizes that the obsessional thoughts, impulses, or images are a

product of his/her own mind (not imposed from without, as in thought insertion).

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2. Compulsions are defined by the following 2 criteria:

1. The person performs repetitive behaviors (eg, hand washing, ordering, checking)

or mental acts (eg, praying, counting, repeating words silently) in response to an

obsession or according to rules that must be applied rigidly.

2. The behaviors or mental acts are aimed at preventing or reducing distress or

preventing some dreaded event or situation; however, these behaviors or mental

acts either are not connected in a realistic way with what they are meant to

neutralize or prevent or they are clearly excessive.

B. At some point during the course of the disorder, the person recognizes that the obsessions

or compulsions are excessive or unreasonable. This does not apply to children.

C. The obsessions or compulsions cause marked distress; are time consuming (take >1 h/d);

or significantly interfere with the person's normal routine, occupational or academic

functioning, or usual social activities or relationships.

D. If another Axis I disorder is present, the content of the obsessions or compulsions is not

restricted to it, such as preoccupation with food and weight in the presence of an eating

disorder, hair pulling in the presence of trichotillomania, concern with appearance in

body dysmorphic disorder, preoccupation with drugs in substance use disorder,

preoccupation with having a serious illness in hypochondriasis, preoccupation with

sexual urges in paraphilia, or guilty ruminations in the presence of major depressive


E. The disorder is not due to the direct physiologic effects of a substance or a general

medical condition. Specify if : The additional "with poor insight" is made if, for most of

the current episode, the person does not recognize that the symptoms are excessive or


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2.5. Clinical Syndromes

ICD-10 classifies OCD into three clinical subtypes which are :

1. Predominantly obsessive thought or ruminations,

2. Predominantly compulsive acts (compulsive rituals), and

3. Mixed obsessional thoughts and acts

Depression is very commonly associated with OCD. It is estimated at least half the

patient of OCD have major depressive episodes while many other have mild depression. There

are several clinical syndromes have been described in literature, although admixtures are

commoner than pure syndromes. Those major clinical syndromes are:

i. Washers (contamination)

This is the most common type. Here the obsession is of contamination with dirt,

germs, body excretions and the like. The compulsion is washing of hands or the

whole body, repeatedly many times a day. It usually spreads onto washing of

clothes, bathroom, bedroom, door knobs and personal articles, gradually. The

person tries to avoid contamination but unable to, so washing becomes a ritual.

ii. Checkers (doubt)

In this type the person has multiple doubts, for example the door has not been

locked, kitchen gas has been left open, counting of money was not exact and etc.

the compulsion, of course, is checking repeatedly to remove the doubt. Any

attempts to stop the checking leads to mounting anxiety before one doubt has

been cleared, other doubts may creep in.

iii. Pure obsession (intrusive thought)

This syndrome is characterized by repetitive intrusive thoughts, impulses or

images which are not associated with compulsive acts. The content is usually

sexual or aggressive in nature. The distress associated with these obsessions is

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dealt usually by counter-thought for example praying, “undoing” actions, asking

for reassurance and counting but not with rituals.

iv. Primary obsessive slowness (symmetry)

It is characterized by several obsessive ideas and or extensive compulsive rituals,

in the relative absence of manifested anxiety. This leads to marked slowness in

daily activity. Usually the person demand on being need for symmetry and precise

arranging so in order to neutralize it they will continue Ordering, arranging,

balancing, straightening until "just right" or perfect in their eyes.

v. Other symptoms patterns

There are other types such as hoarders who will found it hard to give or throw

away their things even if it not valuable at all. Others include the religious


2.6. Differential Diagnosis

OCD is sometimes difficult to distinguish from certain other disorders. Obsession and

compulsion may appear may appear in the context of other syndromes, which can raised the

question whether obsession and compulsion are a symptom of another disorder or whether both

OCD and another disorder are present.

2.6.1. Other Anxiety Disorder

Both OCD and other anxiety disorders are characterize by the used of avoidance to

manage anxiety. However OCD is distinguish from other anxiety disorder by the present of the

compulsion. In social or specific phobias, fears are circumscribed and related by specific triggers

or social situation. Although the circumscribed situations may initially trigger obsession and

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compulsion in OCD, triggers in OCD become more generalize over time, unlike the triggers

from social phobia and specific phobias the evoking situation will remain circumscribe.

2.6.2. Gilles de la Tourrete’s syndrome

Complex major tics of Tourrete’s syndrome may be difficult to distinguish from OCD

compulsions. Both tics and compulsions are preceded by an intensive urge and are followed by a

feeling of relief. However, OCD compulsion are usually preceded by both anxiety and

obsessional concerns. Whereas in Tourrete’s syndrome the urge to perform a tic is not preceded

by an obsessional fears

2.6.3. Hypochondriasis

Fears of illness that occur in OCD referred as somatic obsession may be difficult to

distinguish from Hypochondriasis. Usually, however patients with somatic obsession have other

current or past classic OCD obsession that unrelated to illness concerns. Unlike patient with

OCD, patient of Hypochondriasis experience somatic and visceral sensation.

2.6.4. Obsessive Compulsive Personality Disorder (Anankastic)

Obsessive compulsive personality disorder is a lifelong maladaptive personality style

characterized by perfectionism, excessive attention to details, rigidity, indecisiveness, restricted

affect, lack of generosity, and hoarding. Although perfectionist and indecisiveness are relatively

common traits in patient with OCD, the distinction between OCD and OCPD is important.

Unlike OCPD, OCD is characterized by distressing, time consuming ego dystonic obsessions and

repetitive rituals aim at diminishing the distress engendered by obsessional thinking. In contrast

OCPD features are considers ego syntonic.

2.6.5. Other conditions

OCD can be distinguishing from schizophrenia by the absence of other schizophrenic

symptoms, and patient with schizophrenia usually do not have a good insight and also more

bizarre symptoms. Other condition include other tics disorder, temporal lobe epilepsy and

occasionally trauma and post encephalitic complications.

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2.7. Prognosis

Obsessive compulsive disorder can now be effectively treated in up to 70% of cases. The

prognosis tends to be worse the more reasonable the preoccupation, for example checking that

the house is looked before leaving home has poorer prognosis than pointless rituals such as

walking between the cracks in the pavement.

Other than that the outcome is worse when individuals do not realize their obsessions and

or compulsions are not reality based. Although up to 25 percent of patient may refuse cognitive

behavioral therapy, those who complete it show a 50 to 80 percent reduction in OCD symptoms

after 12 to 20 sessions

2.8. Treatment

2.8.1. Psychotherapy

There are two types of psychotherapy that can be done to OCD patient. The first one is

the psychoanalytic psychotherapy. This type of psychotherapy is used in certain patients who are

psychologically oriented especially those with anankastic personality. Secondly, is the supportive

psychotherapy which is an important adjunct to other modes of treatment. Supportive

psychotherapy is also needed by the family members.

2.8.2. Behavior and Cognitive Behavioral Therapy

Behavior modification is an effective mode of therapy with a success rate as high as 80%

especially for the compulsive acts. It is customary these days to combine the cognitive

behavioral therapy with behavior therapy. This involves graded self exposure and self imposed

response prevention of ‘undoing’ of obsession through compulsions, and / or cognitive therapy.

The techniques that often used are thought stopping, response prevention, systematic

desensitization and modeling.

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2.8.3. Drug Treatments

i. Benzodiazepines

For example alprazolam and clonazepam, but they have limited role in controlling

anxiety as adjuncts and should be used very sparingly.

ii. Antidepressant

Some patients may improve dramatically with specific serotonin reuptake

inhibitors (SSRi)

Clomipramine (75-300mg/day), non specific serotonin reuptake inhibitors

(SRI), was the first drug used effectively in the treatment of OCD. The

response is better in the presence of depressive symptoms, but many

patients with pure OCD also improve substantially.

Fluoxetine (20-80mg/day), is a good alternative to clomipramine and often

preferred these days for its better side effects profile.

Fluvoxamine (50-200mg/day), marketed as specific anti-obsessional SSRI

drug, while paroxetine (20-40mg/day), and setraline (50-200mg/day) are

also effective in some patients.

iii. Antipsychotics

These are occasionally used in low doses in the treatment of severe, disabling

anxiety. Some example are haloperidol, risperidone, olanzepine, aripiprazole and


iv. Buspirone

Has also been used beneficially as adjuncts for augmentation of SSRI, in some


2.3.4. Electroconvulsive Therapy (ECT)

In the presence of severe depression with OCD, ECT may be needed. ECT is particularly

indicated when there is a risk of suicide and/or when there is a poor response to the other modes

of treatment. However ECT is not the treatment of first choice in OCD.

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2.3.5. Psychosurgery

In severe, intractable, chronic and incapacitating cases, where all other treatments have

failed, streotactic site specific brain surgery has been reported to be successful. This has included

the used of radioactive yttrium implants and more recently, non invasive proton, electron and X-

ray techniques. Anterior cigulotomy, capsulotomy and limbic leucotomy have also been found to

be effective in 25-30 percent of such cases. All involve the separation of the frontal cortex from

deep limbic structures. Sadly, psychosurgery only available as a treatment choice at a very few

centers’ throughout the world.

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Obsessive–compulsive disorder (OCD) is a mental disorder characterized by intrusive

thought that produce anxiety, by repetitive behaviors aimed at reducing anxiety, or by

combinations of such thoughts known as obsession and behaviors or rituals that is compulsion.

There were several theories suggesting the etiology of OCD and the most systematic is

the Psychodynamic Theory purposed by Sigmund Freud. It describe if the anal sadistic phase is

disturbed in the early childhood it can cause OCD in the later life. Other than that, two other

theories are the biological and behavioral theories.

The best treatment for OCD is behavioral therapy (BT) and cognitive behavioral therapy

(CBT) which have high success rate at 80%. Other modes of treatment are drug treatment that is

SSRI, TCA, benzodiazepines etc. and psychotherapy which consist of supportive and

psychoanalytic. Only when this modes of treatment can’t be done the psychosurgery and ECT is

an option.

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Synopsis of Psychiatry Behavioral Sciences/Clinical Psychiatry 9 th Edition, United Stated

of America, Lippincott William and Wilkins; 616-623

2. Michael B. First, 1994: Obsessive Compulsive Disorder, Anxiety Disorder, Diagnostic

Criteria from Diagnostic and Statistical Manual of Mental Disorder 4th Edition (DSM-4),

United States of America, American Psychiatric Association; 207-209

3. William M.G., (2010, March 8). Obsessive Compulsive Disorder. Emedicine, from


4. Puri B.K., Laking P.J., Treasaden I.H., 2002: Obsessive-Compulsive Disorder

(Obsessive-compulsive neurosis);Neurotic and Other Stress- Related Anxiety Disorder,

2nd Edition Textbook of Psychiatry, Philadelphia, Churchill Livingstone; 217-221

5. Ahuja N., 2006: Obsessive-Compulsive Disorder; Neurotic, Stress Related and

Somatoform Disorders, A Short Textbook of Psychiatry 6th Edition, New Delhi,Jaypee

Brothers; 101-105

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